Ulcera lingual como signo único de infección recurrente por micobacteria en un paciente con VIH/SIDA

Se describe un paciente con VIH/SIDA en el que se identificó una infección por micobacteria en la mucosa bucal, probablemente tuberculosis, en un centro de referencia para VIH/SIDA de la Ciudad de México. El propósito del presente informe es describir los hallazgos clínicos e histológicos en un paciente con VIH/SIDA, quien después de haber sido tratado exitosamente para tuberculosis ganglionar 4 años antes, presentó una úlcera lingual como único signo que sugirió recurrencia de infección por micobacteria, probablemente tuberculosis. Hombre de 39 años de edad, atendido desde 1991 en el Instituto Nacional de Ciencias Médicas y Nutrición 'Salvador Zubirán', por el diagnóstico de infección con VIH. En 1999, el paciente presentó tuberculosis ganglionar, recibiendo tratamiento antifímico con involución de las adenopatías y desaparición de los síntomas sistémicos. En mayo del 2003 acudió a consulta por presentar una úlcera superficial en lengua, dolorosa, de 4 meses de evolución, de 0.7 cm. de diámetro, bien circunscrita, crateriforme, con bordes ligeramente elevados, irregulares e indurados. El estudio histopatológico mostró inflamación granulomatosa crónica con células gigantes multinucleadas sugestivas de infección por mi-cobacteria, lo cual hizo pensar en recurrencia de tuberculosis, por lo que se indicó rifampicina, pirazinamida, etambutol y estreptomicina. En junio del 2003 el paciente inició TARAA, que incluyó dos ITRAN y un ITRNN. La lesión lingual evolucionó favorablemente, con cicatrización parcial a la primera semana y remisión total a los 45 días del inicio del tratamiento antifímico; a los 7 meses de seguimiento permanece sin lesión. El presente caso tiene la particularidad de que la úlcera lingual fue la única manifestación de infección por micobacteria, sugestiva de tuberculosis, en un paciente con VIH/SIDA, que pudo ocurrir como resultado de la recurrencia del episodio previo de TB ganglionar.The report describes an HIV/AIDS patient seen at a referral center in Mexico City, in whom a mycobacterial infection in the oral mucosa, probably tuberculosis (TB) was identified. The purpose is to describe the clinical and histological findings in an HIV-infected patient, who after being treated successfully for tuberculous lymphangitis 4 years ago, presented with a lingual ulcer as the only suggestive sign of recurrence of mycobacterial infection, probably M. tuberculosis. A 39-year-old man seen inthe HIV clinic of the Instituto Nacional de Ciencias Médicas y Nutrición 'Salvador Zubirán' in Mexico City since 1991 for HIV infection. In 1999 the patient developed tuberculous lymphangitis; he was managed with a 4-drug regimen for 12 months, with improvement of local and systemic symptoms. In May of 2003, the patient presented a painful superficial lingual ulcer, 0.7 cm in diameter, well circumscribed, crateriform with slightly elevated, irregular and indurated borders, of 4 months duration. The histopathological examination showed chronic granulomatous inflammation with giant multinucleated cells, suggestive of mycobacterial infection, and recurrence of TB was considered. Rifampin, isoniazide, pyrazinamide, ethambutol and streptomycin were administered. The lingual lesion improved with partial healing at the first week and total remission at 45 days after the beginning of the antituberculous treatment. In June, 2003, the patient began highly active antiretroviral therapy (HAART) that included two NRTIs and one NNRTI. At 7 months of follow-up, the patient remains free of lingual lesions. The particularity of the present case is that the lingual ulcer was the only sign of infection by mycobacteria, suggestive of TB, in an HIV/AIDS patient that probably represented a recurrence of a previous episode

Oral health in older adults with cancer

Cancer is a disease of older adults, with 60% of cancer diagnoses and 70% of cancer deaths occurring in individuals &ge; 65 years. Normal oral aging may transition to disease in the presence of one or more potential modifiers, such as a new oncological diagnosis or a new treatment. Oral conditions in patients with cancer cause significant morbidity. Previous work suggests that oral conditions are neither elicited/assessed/reassessed nor well-managed or investigated in older patients. However, frequently reported oral conditions in patients undergoing cancer therapy include xerostomia, dysgeusia, candidiasis, mucositis, and dental caries. Some oncological treatments such as hematopoietic stem cell transplant or chemotherapy/radiotherapy for head and neck cancers entail higher risks of oral complications. No specific recommendations in the case of older adults with cancer-associated oral conditions are available. Treatment recommendations are based on low levels of evidence and/or evidence extrapolated from younger patients with cancer.</p

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

© 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 licenseBackground: 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods: This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494. Findings: Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation: Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding: National Institute for Health Research Global Health Research Unit

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

© 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licenseBackground: Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide. Methods: A multimethods analysis was performed as part of the GlobalSurg 3 study—a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital. Findings: Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3·85 [95% CI 2·58–5·75]; p<0·0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63·0% vs 82·7%; OR 0·35 [0·23–0·53]; p<0·0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer. Interpretation: Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised. Funding: National Institute for Health and Care Research